Prioritization is needed if we are to know that prioritization is insufficient
Professor Sachs's message was that the poorest countries could not afford even the most basic package of drugs and other interventions that the WHO Commission had identified as "best buys", just as they had been unable to pay for the very low-cost benefits discussed in the World Bank's World Development Report of 1993. These influential reports were, of course, examples of prioritization. Through their efforts, it became clear that large reductions in the burden of disease were possible at very little expense (by international standards). Without priority-setting, this message could not have been made clearly or forcefully.
Prioritization is most important when there is little money
The title of this commentary, "Why prioritize when there isn't enough money?" is meant to provoke: for when else would prioritization be needed? Yet not all priority-setting has the same moral significance. Previous meetings of the professional society for prioritization focused almost exclusively on the health systems of the richest countries. Among the topics that most animated many of the participants were whether the national health systems of northern Europe should offer Viagra on a universal basis. With no prejudice toward those who suffer from male sexual dysfunction, it is easy to judge the relative threat to well-being posed by denial of Viagra to an otherwise-healthy and contented septuagenarian in Norway versus refusal to fund DOTS for a young mother in sub-Saharan Africa. Spending too large a share of national health funds, however meager they may be, on tertiary care facility while higher-priority needs go unfunded is literally lethal in the poorest countries. This is where priority-setting matter most. Professor Sach's thesis does not suggest otherwise. Priority-setting may be insufficient, but it is necessary.
Prioritization can itself increase resources
Prioritization makes resources go further, but it can also lead to greater provision. In this way it addresses Professor Sachs's point directly: if the solution lies in increasing the funds available, setting priorities in the right way is one way to make this happen. The reason is that donors like to see their funds being used effectively and wisely. There is no point to handing over money if it will be stolen, squandered, or frittered away. This is as clear to taxpayers as it is to governments and philanthropists willing to offer aid across international boundaries. Providing assurance that priorities have been set wisely is one way to reassure donors and to maintain or increase the flow of funds.
Perhaps the most widely studied exercise in priority setting was the Medicaid rationing intiative undertaken by the state of Oregon, in the United States, over a decade ago. Medicaid is the national program of health insurance for the poor. The program offers a good package of benefits, but due to provisions in the statues that created the program, about half of those Americans whom the government classifies as poor are ineligible. Oregon officials sought to "ration services, not people", promising to insure every poor citizen in the state with an attenuated set of services. Priority setting would ensure that those who received this insurance would get most of the benefit that was delivered in the standard Medicaid package. Oregon embarked on an elaborate, time-consuming project of priority-setting, involving many thousands of hours by members of the Oregon Health Services Committee and by volunteers from the community. After some false starts, the committee delivered a plan to the citizens of the state that was accepted by Washington and proved to be enormously popular. The Oregon legislature, whose limits on Medicaid spending had provoked the initiative in the first place, found the new program worthy of extra financial support.
However, when the program was evaluated by external observers (including the Office of Technology Assessment – an agency of the United States Congress – and numerous individual scholars, including this author), the process of priority-setting lost some of its apparent rationality and its ability to save money. In the end, what accounted for the program's popular (and deserved) acclaim may have been the extra funds appropriated by the legislature.
A second example is the previously-mentioned World Development Report of 1993, whose pioneering effort in priority-setting, identifying a highly effective package of basic services at very low cost, is said to have been among the influences on Bill Gates in choosing international public health as the target of philanthropy.
A third example is, once again, WHO's Commission on Macroeconomics and Health. Professor Sachs, its chair, hopes to use the evidence it brought to bear on priority-setting to win the commitment of the richest countries to contribute billions of dollars in aid.